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Sacramento Oral Surgery

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Doctor Preference

Michael H. Preskar, D.D.S.

Reza Fouladi, D.D.S., M.D.

Rola Rabah, D.D.S., M.D.

Sarah Kuo, D.D.S.

No Preference

Location Preference

7551 Timberlake Wy. • Suite 120 • Sacramento, CA 95823 • 916.423.4092 • FX 916.423.3125

Yes No

2503 K Street • Sacramento, CA 95816 • 916.448.4500 • FX 916.448.2322

Yes No

1603 Eureka Road • Suite 100 • Roseville, CA 95661 • 916.782.6868 • FX 916.782.687

Yes No

Patient Information

Name

Date of Birth

Parent / Guardian Name

Contact Telephone

Contact E-Mail Address

Does the patient require antibiotics prior to dental treatment?

Yes No

Call patient to schedule?

Yes No

Treatment

Referring Information

Referred By

Telephone / E-Mail Address

Preferred Implant System

Preferred Implant System

Bicon Straumann Other

Surgical Template

Surgical Template

Provided by Restorative Dentist Provided by Surgeon

Radiographs or Clinical Photos

PLEASE E-MAIL / UPLOAD ALL DIGITAL X-RAY(S) FOR THIS REFERRAL BY PRESSING THE "Complete and Send" BUTTON BELOW.

AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.

Radiographs / Clinical Photos

Given to Patient Please Take No X-Ray Attached with This Referral

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truForm by PBHS

Sacramento Oral Surgery

Main Header

Patient Information

Doctor Preference

Location Preference

Patient Information

Referring Information

Referring Information

Extraction Information

Procedure Type

Preferred Implant System

Surgical Template

Extractions

Radiographs or Clinical Photos

Case Notes

Case Notes

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Sacramento Oral Surgery

Main Header

Patient Information

Doctor Preference

Location Preference

Patient Information

Referring Information

Referring Information

Extraction Information

Procedure Type

Preferred Implant System

Surgical Template

Extractions

Radiographs or Clinical Photos

Case Notes

Case Notes

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.